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HomeMy Public PortalAbout5036 KAUFFMAN AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)76A663 (� u ITRO APPLI–��t1 ATOOIIV' FOR ELECCAn PERNT ' � (� I hereby affirm that I have a certificate of consent to self insure, or a certificate'tf Worker's Compensation Insurance, or a.certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING,AND SAFETY DIV. copy the�oy( �380QLab.5 Policy N pang _ - FOR APPLICANT.TO FILL IN - JOB 4 ADDRESS 0' Certified copy is hereby furnished. New Residential Bldgs.&Pools' NO. EACH FEE LOCALITY ' 1 &2-Family,Sq.Ft. — $' $ Certif ed copy is filed with the 4FROM g inspection _ NEAREST tme t. Multi-family Sq.Ft. CROSS ST. Residential Swimming Pools ASSESSOR Date Applicant MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTO RS' Outlets:Rea—Light FIRM NAME Sw. OWNER O INSURANCE COMPENSATION - FIrSt'20 MAIL I (This section need not be completed if the work involved by the ADDRESS permit is'for on ' Total No. Additional I certify that a hundred dollars($100)or less.) y in the performance of'the work for which this permit CITY T u[[[[ is issued, I shall not employ any, person in any manner So-as t0 PLAN CHECK become subject to the Workers'•Compensation Laws. Lighting Fixtures First 20 APPucANT: -- -- -- --- Total No. Additional ADDRESS . Date Applicant, RESIDENTIAL APPLIANCES NOT OVER 3 HP,' NOTICE.TO APPLICANT:. If, after making this Certificate of CITY Tel.No. Exemption,you should become.subject toAhe Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. _ rovlsions of the Labor Code,you must forthwith comply with Such PERMIT P p y Power Apparatus&Large.Appliances APPLICAN Q' provisions or this permit shall be deemed revoked.' 4 LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADORES0, 1146 is _ I hereby affirm that'I am licensed under provisions of Chapter 9 ® Over 3 to 10 Incl. CIT r+ (commencing with Section 7000) of Division 3 of the Business and Tel. / Over 16 to 50 Incl. Professions Code, and my license is in full force and effect. - LICENSE OR Over 50 to 100 Incl. REG.NUMBER/11O Over 100 DISTRICT NO. PROCESSED BY U License Numb e Lia Class Services,Swbd.,MCC,&Panelboards �� 0-399 Amp.Under 600VFINAL Contractor - v• Date, DATE U ❑ 400-1000 Amp.Under 600 V VALIDATION UJ I am exempt under Seo. {" Over 1000 Amp,or Over 600 V, FINAL d B.&P.C.for this reason BRANCH CIRCUIT FEES BY C/) Z Date: 15A,or 20A, 120V,Lighting or Recept.. N -- - 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits 41 Or More Branch Circuits Exemption for Reg. Mairit. Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law, _ for the following,reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits _ _ Code): ``r if ;,,1._, (` F71' I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)' __ :•. 7. .and Professions Code). 3?i)AL " _s _ 8 CONSTRUCTION LENDING AGENCY I_• I z+. «%, ps. I hereby affirm that there is a construction lending agency for the f' A% ,�_ performance of the work for which this permit is issued(Sec. 3097,. PERMIT FEE (Sub•Total), "`� ) Civ, C.) ' PLAN CHECKING FEE a yr ?iilt s ,;i "46. t'. Lender's Name " _s PERMIT ISSUING FEE Lender's Address a � i `^� 4�4,,i I certify that I have read this application and under penalty of purjury state TOTAL FEE �. 3 that the ove formation is correct. I agree to comply with all County ordinan s an 'S to laws regulating Electrical wiring,and hereby authorize repres tativ s bf his County to enter upon the above-mentioned property for i s ectio pu se SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PERMITTEE DATE. WORKERS'COMPENSATION DECLARATION 76A663 <: . CE-806G (2-80) A1f if UCAll �ON FOP, ELLSCUNCAL U L,RNT herebyoaffirm that I have a certificate of consent.to self COUNTY OF-LOS ANGELES r —MMING AND SAFETY insure,pr a certificate of Workers'Compensation Insurance,br ` �j a.cer.*fied c ' y thereof S c. 3800,Lab. C.) r � p4 J�� � FOR APPLICANT TO FILL I,N JOB Pol cy o. Company' New Residential Bldgs.&Pools, EACH NO. FEE AD S �L7 0 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft•: $ — $• LOCALITYLe L' LZ Multi-family Sq. Ft. — NEAREST Cpartment.ertified copy is'filed.witli the county building inspection CROSS S•T. Residential Swimming Pools ©/ deOWNER OR , FIRM NAME I Date 5 A liantGlli��- 1 • /' " �� bL PPcOutlets:.Ree% Light� Sw -/, 2;, v [J ADDRESS First 20 CERTTFICATE`OF EXEMPTION FROM WORKERS' Total No Additional , CITY COMPENSATION INSURANCE ��,o� , • } PLAN CHECK 50 � APPLICANT - � (This section need not be completed if the'work involved U by•the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First ZO ADDRESS Additional O Total No. I certify that in the performance of the work for which this Fixed'Appliances'Not Over 1 HP CITY Tel No. permit is issued, I shall not employ.any person in any manner PERMI W so'as to become subject to the Workers' Compensation Laws.- Range_'Heater_'D.W. APPLICANTg2A /[� LU Cn Oven ELI Dryer—W.M. ADDRESS' oU U Date Applicant Top FAU W.H.._; - Hood Fan Other_ CIT L ✓�) Tel N NOTICE TO APPLICANT:'If, after making this Certificate of Disp. Room Air Cond.— ' Q LICENSE OR 7/ /� Exemption; you should become subject to the Workers' REG. NUMBER��//O/ 6e_ilass d] Compensation provisions of the Labor Code, you,must forth- Power Apparatus& Large Appliances DISTRICT NO. P SED BY with comply..with such -provisions 'or .this permit shall be � deemed revoked. Size&Type HP,KW, KVA,.or KVAR Up to.1 Incl. FINAL Over"! to 10 Incl. DATE >�, LICENSED CONTRACTORS DECLARATION VALIDATIONOver 10 to 50 Incl I hereby affirm that I am licensed under provisions of Chapter •Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY ness and Professions.Code,,'and my license is in full force and - effect. .Services �// / 0-200 Amp. Under 600 V t License Numbers-7Z /C2� & Lic.Class -1000 Amp. Under 600 V Contracto�1(J�✓ kms— ��Mte /' �7 � Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole& Appurtenances " Sign with One Branch Circuit I hereby affirm that I•am exempt from the Contractor's Additional Sign Branch Circuits License Law for the following reason.(Section 7031.5, Busi- ness and Professions Code): Misc.Conduits&Conductors •� I, as owner of the property, will do the work and the- Other(See Complete Fee Schedule)— - structure is not intended or offered for sale (Section 7044, Business and Professions Code). " 144,3A CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ;# o o;o o 0 2 . for ,the performance of the work for which this permit is PERMIT FEE (Sub-Total) �U o 0 issued(Sec. 3097,Civi C.). . . 2. 3,7,•4 0 Lender's Name .1 1PLAN CHECKING FEE (One-Fourth Permit Fee) o 0 o 3.7,4 0 Lender's Address PERMIT ISSUING FEE 07.29-80 I certify that'I have read.this application and state that the TOTAL FEE above information is correct:I agree to comply with all County , ordinances and State.laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-menti�oned/property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SignatureofPermittee Date